Provider Demographics
NPI:1457326266
Name:PETROVIC, LIDIJA (MD)
Entity Type:Individual
Prefix:
First Name:LIDIJA
Middle Name:
Last Name:PETROVIC
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 31309
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-0309
Mailing Address - Country:US
Mailing Address - Phone:323-442-2582
Mailing Address - Fax:323-442-2588
Practice Address - Street 1:1510 SAN PABLO ST FL 6
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-5320
Practice Address - Country:US
Practice Address - Phone:323-442-4815
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY226218207ZP0101X
CAA52273207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ54738ZOtherGROUP BLUE SHIELD #
CAZZZ94714ZOtherGROUP BLUE SHIELD #
CAW7801BOtherGROUP MEDICARE #
CAGR0101420OtherGROUP MEDICAID #
CALAB28654FOtherGROUP MEDICAID #
CAHW7801BOtherGROUP MEDICARE #
CAHW7801AOtherGROUP MEDICARE #
CAZZZ31029ZOtherGROUP BLUE SHIELD #
CAGR0101421OtherGROUP MEDICAID #
CALAB28654FOtherGROUP MEDICAID #
CAW7801BOtherGROUP MEDICARE #
NY52R651Medicare ID - Type Unspecified